Student Referral Form Online Form: Student Referral Form "*" indicates required fields 1General Information2Home School Info3Parents / Guardian Info4Student Information5Required Attachments6Referral Reason General InformationReferral Date* MM slash DD slash YYYY Preferred language in student household (if other than English) Translator needed? Yes No Student Name* Birth Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Grade* Referral Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Student CellStudent Email IL SIS #* Home Address* Street Address City ZIP Code Home School InfoHome School* Contact (Home School)* Email (Home School) Parents / Guardian InfoParent Guardian Name #1* First Last Relationship to Student (Parent/Guardian #1)* Parent Guardian Address #1* Street Address City ZIP Code Lives With?* Cell Phone (Parent/Guardian #1)*Email (Parent/Guardian #1)* Parent Guardian Name #2* First Last Relationship to Student (Parent/Guardian #2)* Parent Guardian Address #2* Street Address City ZIP Code Lives With?* Cell Phone (Parent/Guardian #2)*Email (Parent/Guardian #2)* Student InformationMust be completed in fullDays enrolled*Last 176 daysExcused absences*Unexcused absences*Days tardy*Days suspended*Does student have an IEP:* Yes No Does student have a 504:* Yes No Does student have an RTI plan:* Yes No Is student eligible for free or reduced lunch:* Yes No McKinney-Vento Act:* Yes No Required Attachments to Process the ReferralPremier's Individiualized Learning Plan (ILP)* Fill out online form Attach downloaded form You'll be redirected to the ILP form once you submit this form.Premier's Individualized Learning Plan (ILP)* Drop files here or Select files Max. file size: 250 MB. Attendance data for last 176 school days Drop files here or Select files Max. file size: 250 MB. Documentation of academic, behavior & attendance interventions* Drop files here or Select files Max. file size: 250 MB. Copy of IEP, 504, RTI, Contract or Expulsion Letter (if applicable)* Drop files here or Select files Max. file size: 250 MB. Updated transcript* Drop files here or Select files Max. file size: 250 MB. Discipline records* Drop files here or Select files Max. file size: 250 MB. Current schedule & grades* Drop files here or Select files Max. file size: 250 MB. Student Removal InformationIf the student is removed from Premier Academy, they will:* Will be removed from the Home School for the remainder of the semester/school year/expulsion will go into effect Will be removed from Premier and transfer back to Home School Referral ReasonReferral Reason* RSSP TAOEP RSSP ReferralRSSP: Students being referred for RSSP must maintain RCDTS Home School enrollment within the district and have their RCDTS Serving School enrollment changed to 24-000-0000-00-9301. Any expelled student must be re-enrolled and administratively transferred. Required Length of Placement* (required for RSSP/not to exceed 2 years)Primary Referral Reason(s)* RSSP Suspension Eligible – student has been suspended at least twice for a period of 4-10 days for gross misconduct or involved in conduct that can be demonstrated as serious/repetitive/cumulative PA 97-0495 RSSP Suspended & Administratively Transferred – student was suspended in excess of 20 days RSSP Expulsion Eligible – student was expulsion-eligible due to serious/repetitive/cumulative conduct and is transferred in lieu of expulsion PA 97-0495 RSSP Expelled & Administratively Transferred – student was expelled & administratively transferred Secondary Referral Reason(s)* Alcohol – liquor law violations, possession, use, sale Disorderly Conduct – disruptive behavior Drugs – (excluding alcohol and tobacco) – illegal drug possession, sale, use/under the influence Fighting (mutual altercation) battery, and/or physical altercation Harassment (nonsexual) – physical, verbal, or psychological Insubordination – disobedience to school staff or school personnel Robbery – taking of things by force or theft Threats – including school threats Vandalism – damage to school or personal property Violation of School Rules – disobeying school rules Weapons Possession – firearms and other weapons Other Offenses (must check 1 or more that corresponds with suspension or expulsion)Please describe the other offensesTAOEPTAOEP: Students must maintain RCDTS Home School enrollment within the district and have their RCTDS Serving School enrollment changed to 24-000-0000-00-9201. Estimated Length of Placement* Primary Referral Reason(s)* TAOEP Chronic Truant – student who is absent w/o valid cause for 5% or more of the previous 180 regular school attendance days TAOEP Truant – student who is absent w/o valid cause from such attendance for a school day or portion thereof TAOEP Potential Dropout from grades 6-12 – student whose school absences or pattern of school attendance impedes the student’s learning or contributes to the student’s failure of meeting learning standards TAOEP Dropout from grades 6-12 – student whose name has been removed from the district enrollment roster for reasons other than death, extended illness, or graduation and has not been transferred to another school Drop Out Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Drop Out Reason* Secondary Referral Reason(s)* Credit Deficient – high school student who has not earned adequate credit for their appropriate grade level toward graduation Court/Law Mandated – student whose participation in TAOEP has been recommended/required by law enforcement or court Drug/Alcohol Problems – student who has been identified as having drug and/or alcohol problems Health Problems – student having physical or emotional health conditions that place them at risk of dropping out of school High Failure Rate - student who has failed at least 20% of academic courses in previous grade period Low Achievement – student who falls below the district mean achievement levels in both reading & math Low Income – a low-income student as indicated by receiving free lunch/public assistance Tardiness – a student who comes to classes late, repetitively Teen Parent – a student who is a teen parent and who has not received a high school diploma or GED Other Offenses Please describe the other offensesTruancy Interventions/Services* Student conference with Counselor/Dean/Administrator Parent conference with School Administrator Phone calls to parent/guardian Referral to outside social services agencies School Nurse Home visits Issued Med Doc form Social Work services (check all that apply)Please check the following documents that have been utilized and included with this referral:* 1st attendance letter 2nd attendance letter with medical documentation 3rd attendance letter Officer Name
Edgenuity/Imagine Learning
Staff Email
